The female athlete triad and the impact on the endocrine system

The passage of Title IX in 1972 dramatically improved the opportunities for young women to compete in athletic activities at the college level and the benefits are self-evident. The prospect of a college scholarship has also improved the opportunity for competitive sports at the high school level. The one downside in my opinion is the increased number of high school teens and young women in college who suffer the consequences of over training — the female athlete triad (1, 2). I guess not surprisingly, every article I searched while preparing this blog studiously avoided the obvious abbreviation — FAT. One wonders whether this triad might explain why some competitors at the Beijing Olympics looked several years younger than their stated age.

While probably not as dire as anorexia or bulimia which are also quite prevalent at college, the impact on the endocrine system is not dissimilar. The major clinical manifestations of the triad are an eating disorder, altered menstrual function (oligomenorrhea or amenorrhea), and stress fractures. Altered menstrual function is not something that the athlete would be comfortable discussing with the coach. In medical school we do not learn much about menstrual synchrony but college roommates know this phenomenon quite well. But who wants to “turn in” a friend?! Low bone mineral density is far more prevalent than fractures but does not come to clinical attention since it is not measured routinely. (Nor do I think it should be for the same reasons I discussed in a recent blog about the recommendation to screen young women with type 1 diabetes.) This puts a major burden on trainers and coaches to look for signs of an eating disorder which is also no easy task, since most of these athletes are likely to have more muscle and look more fit than a similar-aged woman with anorexia. Of course it is extremely difficult to detect a possible eating disorder if you choose not to look.

The two citations below emphasize the importance of education of the athlete and reinforcement from coaches and trainers prior to the start of the season. But what can we as clinicians do for these young women should they come to us as a patient? Regrettably not much based on my reading of the literature and limited clinical experience. (I see more male athletes concerned about their gynecomastia from abuse of testosterone than women with the triad.) Weight gain to the point where normal menstrual function is restored appears to be the only well-documented successful remedy, but that is a hard message to get across. It may be helpful to remind the patient that Michael Phelps won eight gold medals on a daily calorie intake widely reported in our local newspapers to be 10,000 calories a day, and that there are a number of very prominent role models who can compete at the highest levels even after they have had children (Mary Decker, Lindsay Davenport and Dana Torres come quickly to mind).

You might wonder why I am composing a blog on a topic on which I have limited personal experience. A fair question. I have the good fortune to be mentoring a pre-med college senior, R. Alan Mitteer Jr., who is preparing an extensive literature review on this topic and teaching me more about the topic than I am mentoring him on how to do the search and write up his findings. Is there anything more rewarding than being directly involved in the training of the next generation?

For more information:
Bonci CM, Bonci LJ, Granger LR, et al. National athletic trainers' association position statement: preventing, detecting, and managing disordered eating in athletes. J Athl Train. 2008;43:80-108.
Nattiv A, Loucks AB, Manore MM, et al. American College of Sports Medicine position stand. The female athlete triad. Med Sci Sports Exerc. 2007;39:1867-1882.